Fiona Samuels

Health regains but livelihoods lag: findings from a study with people on ART in Zambia and Kenya.

Abstract Although ART is increasingly accessible and eases some stresses, it creates other challenges including the importance of food security to enhance ART-effectiveness. This paper explores the role livelihood strategies play in achieving food security and maintaining nutritional status among ART patients in Kenya and Zambia. Ongoing quantitative studies exploring adherence to ART in Mombasa, Kenya (n=118) and in Lusaka, Zambia (n=375) were used to identify the relationship between BMI and adherence; an additional set of in-depth interviews with people on ART (n=32) and members of their livelihood networks (n=64) were undertaken. Existing frameworks and scales for measuring food security and a positive deviance approach was used to analyse data. Findings show the majority of people on ART in Zambia are food insecure; similarly most respondents in both countries report missing meals. Snacking is important for dietary intake, especially in Kenya. Most food is purchased in both countries. Having assets is key for achieving livelihood security in both Kenya and Zambia. Food supplementation is critical to survival and for developing social capital since most is shared amongst family members and others. Whilst family and friends are key to an individuals livelihood network, often more significant for daily survival is proximity to people and the ability to act immediately, characteristics most often found amongst neighbours and tenants. In both countries findings show that with ART health has rebounded but livelihoods lag. Similarly, in both countries respondents with high adherence and high BMI are more self-reliant, have multiple income sources and assets; those with low adherence and low BMI have more tenuous livelihoods and were less likely to have farms/gardens. Food supplementation is, therefore, not a long-term solution. Building on existing livelihood strategies represents an alternative for programme managers and policy-makers as do other strategies including supporting skills and asset accumulation.

Can Cash Transfer Programmes Have ‘Transformative’ Effects?

ABSTRACT Cash transfers (CTs), for all their evident success in relieving poverty, have been criticised for failing to incorporate transformative elements into their programme design. In recent years changes have been introduced into the design of CT programmes that go some way towards addressing this concern. This article critically engages the meaning of transformative social protection and introduces a collection of papers that examine whether and under what conditions cash transfers can be ‘transformative’. Among the issues addressed are whether CTs can be catalysts leading to positive changes, material, subjective and relational in the lives of poor people; what are the social effects of CTs for beneficiaries, their households and communities; and can they foster horizontal relationships within communities and vertical relationship with the state through developing forms of social accountability and citizenship engagement?

‘Being Able to Breathe Again’: The Effects of Cash Transfer Programmes on Psychosocial Wellbeing

Abstract The multidimensional nature of poverty and vulnerability and the role of psychosocial dimensions in achieving wellbeing are increasingly being recognised, yet development programme assessments still tend to focus on material outcomes. We situate this article within a wellbeing framework and after reviewing evidence on the psychosocial effects of cash transfer programmes, we explore findings from a qualitative and participatory study on beneficiary experiences of unconditional cash transfers in the Middle East and Sub-Saharan Africa. Narratives reveal how cash transfers can improve psychosocial wellbeing at individual level and in relation to others suggesting that psychosocial dimensions need to be considered when planning, implementing and evaluating cash transfer programmes.

AIDS and Agriculture in Zambia

Background Because agriculture is the livelihood base for the majority of people affected by AIDS in sub-Saharan Africa, the interactions between AIDS and agriculture, and their implications for policy and programming, are of fundamental importance. Objective This paper summarizes evidence from three RENEWAL (Regional Network on AIDS, Livelihoods, and Food Security) research studies and one policy review on the interactions between AIDS and agriculture in Zambia and their implications for future policy and programming. Methods The unit of analysis adopted for each study varies, spanning the individual, household, cluster, and community levels, drawing attention to the wider socioeconomic landscape within which households operate. Results This paper identifies the ways in which livelihood activities, within the prevailing norms of gender, sexuality, and perceptions of risk in rural Zambia, can influence susceptibility to HIV, and how the nature and severity of the subsequent impacts of AIDS are modified by the specific characteristics and initial conditions of households, clusters, and communities. Conclusions The findings demonstrate the importance of studying the risks, vulnerabilities, and impacts of the AIDS epidemic in the context of multiple resource flows and relationships between and within households—and in the context of other drivers of vulnerability, some of which interact with HIV and AIDS. The paper addresses several factors that enable or hinder access to formal support programs, and concludes by highlighting the particular importance of engaging communities proactively in the response to HIV and AIDS, to ensure relevance, sustainability, and scale.

Advocacy for school-based sexuality education: lessons from India and Nigeria

Drawing on evidence from a wider study on the cost and cost-effectiveness of sexuality education programmes in six countries, and focusing on the examples of India and Nigeria, this paper argues that advocacy is a key, yet often neglected component of school-based sexuality education programmes, especially where sex and sexuality are politically or culturally sensitive issues. It also suggests that advocacy is not a one-off activity but needs to be carried out continuously and adapted as contexts and needs change. Overall, this piece recommends that advocacy should be a key component of sexuality education work, and needs to be planned and budgeted for. Without such investment, country-level sexuality education programmes are likely to fail.

Drivers of health system strengthening: learning from implementation of maternal and child health programmes in Mozambique, Nepal and Rwanda

Abstract There is a growing understanding that strong health systems are crucial to sustain progress. Health systems, however, are complex and much of their success depends on factors operating at different levels and outside the health system, including broader governance and political commitment to health and social development priorities. Recognizing these complexities, this article offers a pragmatic approach to exploring the drivers of progress in maternal and child health in Mozambique, Nepal and Rwanda. To do this, the article builds on a semi‐systematic literature review and case study findings, designed and analysed using a multi‐level framework. At the macro level, governance with effective and committed leaders was found to be vital for achieving positive health outcomes. This was underpinned by clear commitment from donors coupled by a significant increase in funding to the health sector. At the meso level, where policies are operationalized, inter‐sectoral partnerships as well as decentralization and task‐shifting emerged as critical. At micro (service interface) level, community‐centred models and accessible and appropriately trained and incentivized local health providers play a central role in all study countries. The key drivers of progress are multiple, interrelated and transversal in terms of their operation; they are also in a constant state of flux as health systems and contexts develop. Without seeking to offer a blueprint, the study demonstrates that a ‘whole‐system’ approach can help elicit the key drivers of change and potential pathways towards desirable outcomes. Furthermore, understanding the challenges and opportunities that are instrumental to progress at each particular level of a health system can help policy‐makers and implementers to navigate this complexity and take action to strengthen health systems.

Psychosocial support for adolescent girls in post-conflict settings: beyond a health systems approach

Abstract Adaptive and adequately resourced health systems are necessary to achieve good health outcomes in post-conflict settings, however domains beyond the health system are also critical to ensure broader wellbeing. This paper focuses on the importance of psychosocial support services for adolescent girls in fragile contexts. Its starting point is that adolescence is a pivotal time in the life course but given the physical, cognitive and emotional changes triggered by the onset of puberty, it can also be a period of heightened sensitivity and vulnerability to trauma, social isolation, bullying by peers, a lack of supportive adults and gender-based and sexual violence. Our findings highlight why humanitarian and biomedical approaches in their current form are inadequate to address these complexities. Drawing on qualitative fieldwork (consisting of in-depth and key informant interviews as well as group discussions in Gaza, Liberia and Sri Lanka involving a total of 386 respondents across the three countries), we argue that going beyond biomedical approaches and considering the social determinants of health, including approaches to tackle discriminatory gendered norms and barriers to service access, are critical for achieving broader health and wellbeing. While all three case study countries are classified as post-conflict, the political economy dynamics vary with associated implications for experiences of psychosocial vulnerabilities and the service environment. The study concludes by reflecting on actions to address psychosocial vulnerabilities facing adolescent girls. These include: tailoring services to ensure gender and age-sensitivity; investing in capacity building of service providers to promote service uptake; and enhancing strategies to regulate and coordinate actors providing mental health and psychosocial support services.

One Step Forwards half a Step Backwards: Changing Patterns of Intimate Partner Violence in Bangladesh

Intimate partner violence (IPV) is still rampant in Bangladesh despite a strong national legal framework and a range of governmental as well as non-governmental initiatives to tackle violence against women and girls (VAWG). This paper explores the influence of social norms on the persistence of IPV in Bangladesh as well as a possible backlash occurring despite progress in many areas in relation to tackling VAWG. Qualitative data were collected through 40 key informant interviews, 21 in-depth interviews with survivors of IPV and with married men, 11 focus group discussions and seven intergenerational trios, in two districts of Bangladesh and in Dhaka in 2016. With appropriate consent, interviews were recorded, transcribed and translated from Bengali to English and coded using MAXQDA software. A thematic analysis was then carried out on the coded segments. Findings from our study sample suggest that despite increased awareness of their rights, women and girls still face social norms that create barriers to attaining these rights. Effective governmental and NGO programming might, according to study respondents, result in backlash by men, leading also to changing forms of IPV. Our findings also suggest that increased access to economic resources may not always be protective, while increased education, mobility and access to new technology may be increasing IPV behind closed doors. We argue that the tenacity of the discriminatory gender norms that underlie the attitudes and behaviours of people in Bangladesh is a critical factor for understanding why, despite progress in many areas, IPV persists.